Outdoor activities and behaviors increase the vulnerability of school-age children to malaria infections in south-eastern Tanzania

doi:10.21203/rs.3.rs-2832075/v1

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Research Article

Outdoor activities and behaviors increase the vulnerability of school-age children to malaria infections in south-eastern Tanzania

https://doi.org/10.21203/rs.3.rs-2832075/v1

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published 03 Oct, 2023

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Background: Strengthening malaria control activities in Tanzania has dramatically declined human malaria infections. However, the burden is now higher among school-age children, but with the inconsistency of evidence on risk factors and underlying causes for such an epidemiological shift. This study explored activities and behaviors that increase the vulnerability of school-age children to transmission risk.

Methods: Twenty-four focus group discussions (FGDs) were conducted in three districts of Rufiji, Kibiti and Kilwa in south-eastern Tanzania. Sixteen FGDs worked with school-age children (13 to 18 years) and eight FGDs with their parents.

Results: Routine domestic activities such as fetching water, washing kitchen utensils, cooking, recreational activities such as playing and watching television as well as studying were the reported activities that kept school-age children outdoors late into the evening and therefore, likely to predispose them to malaria infection. Likewise, the social and cultural events such as initiation ceremonies and livelihood activities also kept this age group outdoors from late evening to early night and sometimes past midnight hours. Parents migrating to farms from December to June, leaving behind school-age children unsupervised and the behavior of children sprawling legs and hands while sleeping were also mentioned as drivers increasing school-age children’s vulnerability to infectious mosquito bites.

Conclusion: The risky activities, behaviors, and social events mostly occurring outdoors increase school-age children's vulnerability to malaria infections. The evidence presented calls for the urgent need to integrate outdoor malaria vector control measures into the existing interventions to control infection before bedtime. That will speed up efforts toward having society free of malaria by 2030.

Malaria

Disease reservoir

Outdoor malaria transmission

The efforts to address the burden of malaria in Tanzania led to a decline of 20% from 7.7 million in 2015 to 6.7 million in 2019 (1, 2). Despite the overall reduction, an epidemiological shift is emerging and the age most affected is now school-age children(3–10). Evidence suggests that children of this age group in sub-Saharan Africa carry the highest proportion of asymptomatic malaria infection (9, 11–21). Asymptomatic infection is under-researched, poorly understood and therefore remains untreated (13, 14, 20, 22). To this end, school-age children continue to be the reservoirs of malaria parasites, fueling transmission to other age groups and thus impairing malaria control efforts(11, 20, 23, 24). Appropriately targeted interventions are essential to address transmission to speed up elimination efforts (25, 26).

Evidence from Tanzania indicates the presence of persistent malaria prevalence among school-age children compared to other age groups despite a two-decade-long upscaling of insecticide-treated nets (ITNs) and indoor residual spray (IRS) (1, 2, 8, 16). Malaria prevalence among the school-age stands at 21.6% nationally. The burden is higher than the 14% for the under five reported by the Tanzania Malaria Indicator Survey (TMIS) in 2015–2016 (1, 14). Recent evidence from surveys conducted in the south-eastern Tanzania regions between 2015 and 2021 reported a higher burden to this age group, where the risk of malaria infection among school-age children was twice as higher as the under-five with optimal bed net use of above 80%(16, 17)

Despite the high prevalence among school-age children, drivers of such an unprecedented burden remain unclear, especially in highly endemic areas. This study explored activities and behaviors that increase the vulnerability of school-age children to malaria infections despite the reported optimal bednet coverage and use. Findings from this study will inform and guide the implementers in malaria prevention and control to design cost-effective targeted strategies to control residual malaria transmission, henceforth complementing efforts towards meeting malaria elimination by 2030 in Tanzania (as per the National Malaria Strategic Plan (NMSP) and Global Technical Strategy for malaria (GTS) 2016–2030 (5, 11, 21, 25)

Study Design And Settings

A cross-sectional study using a qualitative approach was conducted in Rufiji, Kibiti and Kilwa districts, south-eastern Tanzania, where two phases of the China-UK-Tanzania project, "Application of Community-based Integrated Strategies to Reduce Malaria (ACOBISREM)” was implemented. Based on epidemiological stratification in Tanzania, the study areas fall within moderate to high transmission settings, with high heterogeneity at the sub-district level(8). From entomological surveys, Anopheles gambiae ss, Anopheles Arabiensis, Anopheles merus, and Anopheles funestus s.s are the major malaria vector species in the areas. (27, 28) Importantly, the survey on mosquito biting behavior in different areas has shown that more than 20 percent of bites by malaria vectors occur in the early night hours before sleeping time. A detailed description of the study area is given elsewhere (16, 17, 29, 30).

Ifakara Health Institute (IHI) implemented phase one of the ACOBISREM project in high-burden areas of the Rufiji district, one of the districts of the Pwani Region in Tanzania, between 2015–2018 (16, 17, 29, 31). The second phase was implemented from 2019–2021 in Rufiji, Kilwa and Kibiti districts to replicate and validate a scaling-up strategy. It succeeded to reduced parasite prevalence by 66%. However, despite the significant reduction, the school-age children group carries the highest disease burden across the study area. (Mlacha et al. unpublished data).

Sampling and Interviewees.

School-age children aged between 5 and 18 years in the study area were recruited. Weekly community testing data from the main study (ACOBISREM) was used to identify the top three villages with the highest asymptomatic malaria prevalence among school-age children in each district. The names of the selected villages are indicated in Fig. 1. Three FGDs with 8 to 12 participants were conducted in each village, one with parents (mixed group male and female) and two with school-age children (separating girls and boys). Separation aimed to ensure that they freely express their experiences and opinions. Village leaders and teachers were fully involved in recruiting participants to increase adherence to the study. The participating parents signed informed consent for themselves, while children below 18 years had their respective parents sign their consent forms. Each FGD took a maximum of one hour and was conducted in village offices or at the school.

Data collection.

All FGDs were digitally recorded and audio records repeatedly listened for consensus and to examine whether data reached saturation to mark the end of data collection in the study site. Twenty-four FGDs were conducted across the study area. Of them, eighteen FGDs were undertaken in Kilwa and Rufiji districts. Only six FGDs instead of nine were launched in the Kibiti district because data reached saturation. Swahili, a common language in the area and nationally, was used for FGDs.

Data management and analysis.

The ecological model guided this study in understanding individual, social, cultural and environmental drivers that increase the vulnerability of school-age children to malaria infections in the study area. Analysis followed a thematic framework approach by Richer and Spencer (32). Audios records were saved in the computer and the external backup device and later transcribed and translated into English, then another person reviewed transcriptions for quality check. Codes were generated thematically; transcriptions were imported to NVivo software for coding then codes were deductively and inductively analyzed. Similarities and differences between themes as well as relations and patterns were considered in the writing results. (33)

Socio-demographic characteristics of the study participants

A total of 205 community members participated in this study during data collection across the study area. Of them, 72 participants (45 male and 27 female) were parents, while 133 were school-age children (65 boys and 68 girls). The average age among school-age children and parents was 15.1 and 44.1 years, respectively. Parents reported agriculture as the main economic activity of all the mentioned occupations. In addition, 95.6% % of all participants from the three districts can read and write.

Main reasons for mosquito-bite exposures among school-aged children.

Evidence gathered suggested seven (7) main reasons behind the increased risk of exposure to mosquito bites among the school-aged children in the study areas: 1. Social activities, 2. Cultural activities, 3. Economic activities, 4. Livelihood activities 5. Sleeping and waking up hours 6: Sleeping and bed-net use behaviors and 7: Risk perception.

Social activities exposing school-age children to mosquito bites

School-age children are mostly exposed to mosquito bites when they are outdoors from evening to bedtime hours. Social activities that would keep them outdoors at night were categorized into i) routine social activities, ii) studying iii) social events and religious ceremonies.

i. Routine social activities.

Household chores and other evening activities performed by school-age children have been mentioned as social activities keeping this age group outdoors and sleeping late almost daily. Both parents and school-age children said routine evening activities such as cooking, bathing outdoors, cutting firewood, fetching water, washing utensils, watching television, socializing at home and spending time kijiweni (places where they gather for socialization), eating and playing outdoors at night are day to day activities exposing school-age children to risk of contracting malaria. The routine activities done by the school-age children were gender-based as per Tanzanian social and cultural norms. Girls were said to be responsible for cooking and washing utensils while boys were spending time kijiweni while playing outside and cutting firewood were the shared activities.

“School-age children are playing outside in the late evening, and daily they are spending many hours watching television” (Parent, Kilwa)

"They are playing hiding games in long grasses where there are many mosquitoes, and parents cannot watch over the children all the times when they are playing” (Parent, Rufiji)

Parents and school-age children highlighted that watching television programs, preferably series (local and international translated into the Swahili language) commonly known as seasons, is one of the exposure factors that may have contributed to high malaria prevalence in this age group. In peri-urban school-age children were watching series and seasons at home while in rural areas, children were watching programs at the centers commonly called kibandaumiza in the Swahili language because majority do not have television (T.V.) at home and others were gathering outside to watch T.V. from a person who has decided to bring their television out so that anyone interested can watch freely. All parents in the study area said the school-age population, both boys and girls spend more time watching television, specifically the series and seasons after classes and during the weekend than other age groups in the communities. They paid 200 TSH to watch the programs per day. These programs start from 19:00 to 23:00 throughout the week. School-age children appeared familiar with the programs, as they could identify the weekly schedule and broadcast time. Most parents across the study area said boys aged 15 years and older were returning home late because they were watching international football and local boxing matches in kibandaumiza, but this was a seasonal activity.

"Kulfi and Goodson's series are broadcasted on Monday to Sunday from 19:00 to 21:00, while Mama Kimbo and the City series are from Monday to Friday from 19:00 to 23:00. But you can watch local movies on the Sinema Zetu channel anytime” (School age child, Rufiji)

“Watching football is not a routine activity. Boys of 15 years and above are the ones going to watch football and boxing, coming back home at 24:00 to 04:00” (School age child, Kilwa)

ii. Studying sessions (night academic sessions).

Studying at night commonly known as preparation studies, is mandatory for national-examination year students (primary school-standard seven and secondary school form two and four students) and other students preparing for mid (in March and September) and end of the term (in June and December) examinations and monthly tests. Pupils and students reported going to classes from 19:00 to 22:30 for private study and returning home, but national examination candidates stayed in school camps under teachers’ supervision. School-age children confirmed not using preventive measures for mosquito bites when studying at night.

"Form one to form four students attend mandatory preparation studies session weekdays from 19:30 to 22:30, but we are not using prevention to mosquito bites because we are spending few hours in the class” (School age child, Kilwa)

"At Chumbi primary school, there are examination preparation sessions from 19:00 to 22:00." (School- age child, Rufiji)

iii. Social events and religious ceremonies

Participants reported ceremonies and social events like wedding ceremonies happening during the dry season and immediately after harvesting in March to July as a potential risk factor that increases the vulnerability of the age group to mosquito bites. During that time, people have money to host parties and the weather is favorable for outdoor parties. Most participants said parties included "vigodoro” (Vigodoro is a kind of music played commonly at night after a social event like weddings and cultural ceremonies. Music played included singeli and bongo flavors, which are mostly liked by youth, attracting school-age children to stay outdoors at night.

"I attend vigodoro parties during the weekends and normally return home at 05:00. We dance the whole night because they play all kinds of good music like bongo flavor, taarab and singeli. Sometimes famous musicians come to our villages." (School-age child, Kibiti)

“School-age children like Musics, specially vigodoro. They can spend a night or come home very late and if parents will not be stickily, even a seven years child can attend the party overnight” (Parent, Kilwa)

Islam is a common religion in the study area. Participants suggested Dhikri ceremonies as a factor exposing the school-age population to mosquito bites because it is conducted outdoors at night. Like other social ceremonies, Dhikri is commonly held after harvesting (March to July) when people have harvested and are financially well.

"Take an example of events like Dhikri, where people should sing and dance. These activities cannot be done while people are in bednet. By the way, we use bednets when people are in bed and not otherwise. They cannot dance with bednets” (Parent, Kilwa)

Cultural activities exposing school-age children to mosquito bites.

Children’s initiation ceremonies involve a school-age population across the study area. It is usually conducted during the dry season and school holidays in June and December to avoid interference with school programs. The practices are locally called Jando for boys and unyago for girls. To boys, this is the time when they are circumcised, while Unyago is conducted for girls aged 12 to 15 when they get their first menstrual period. Most participants in peri-urban and rural areas said the modality of performing children's initiations has changed because majority are taking their boys to the hospital for circumcision instead of camping in the forest as it was in the past years. Contrary to that, participants in rural communities of Kilwa and Kibiti districts reported that Jando was still being conducted in the forest for 2 to 3 weeks. Boys slept in the forest with no protective measures against mosquito bites. Similarly, participants across the study area said unyago takes place at home. Still, initiation ceremonies for both girls and boys are held for 1 to 2 days outdoors, where a child gets gifts from parents and relatives as an incentive for the achievement.

" In the past years, Jando was conducted in the forest to boys of 5 years and above but nowadays, circumcision takes place in the hospital and those who are still interested in traditionally circumcising their children are taking them to villages where they are still doing circumcision in the forest” (Parent, Rufiji)

“Jando is conducted in the forest and boys are staying there for 2 to 3 weeks” (Parent, Kilwa)

Economic activities exposing school-age children to mosquito bites

The economic activities mentioned to be possible exposing school-age children to mosquito bites were mainly (i) agriculture which involved the migration of parents to the farm (ii) fishing

i. Migration of parents to the farm.

Most parents migrate to farmlands from December to June for cultivation, harvesting activities and protecting crops from animals. Farms are far from their households, so migration to the farm is necessary to reduce daily go and return movements. Parents travel and reside in farmlands with the under-five children, leaving behind those studying with elder children or relatives without their parent's care. Missing parents' care increases the risk of spending long hours of the evening and nights outdoors and not using bed nets or not using them correctly. Similarly, school-age respondents across the study area said their parent's migration to Shamba gave them the freedom to watch television for long hours and spend more time outside. Several school-age children said younger children are at higher risk of sleeping without a bednet when parents are not at home because they cannot tuck bed nets properly. Therefore, there is an increase in the risk of mosquito bites compared to when parents are at home.

"…when parents have moved to the farm, I get more time walking around the village and spend time at kijiweni because I am the in-charge in the household deciding the time to go back home at night" (School age child, Kilwa)

"Parent's care is unique and cannot be compared to whoever left with children when they migrated to the farm. Caretaker can order children to go to sleep, but parents would prepare a bed for their children and tuck in bed net for them before telling children to go to bed" (Parent, Kilwa)

ii. Fishing activities expose school-age children to mosquito bites.

Parents in Kilwa, specifically in Somanga village, said elder children who are not students are involved in fishing activities while those studying were doing the work during the weekends. Somanga is located in the peri-urban area near the Indian Ocean. Fishing activity is usually done at night, but sometimes they stay in the camps for a month or more.

“Some of 12 years children are not studying, have graduated standard seven or stopped studying, they are engaging themselves in fishing activities, which is normally done at night" (Parent, Kilwa)

Livelihood activities exposing school-age children to mosquito bites

Routine livelihood activities mentioned were selling food items like donuts, groundnuts, oranges, fish and boiled eggs are conducted by school-age children in the late evening to night hours (18:00 to 22:00) therefore exposing them to mosquito bites. School-age children did these activities to help their parents generate income.

“Children of 11, 12 to 13 years are selling roasted maize, groundnuts, donates, cassava and oranges along the road” (Parent, Rufiji)

"During the weekend, they are helping parents generate family income by selling fish and boiled eggs" (Parent, Kilwa)

Sleeping hours

School-age children were sleeping late than other age groups in the community. They sleep between 22:00 and 24:00. Watching television or attending social events are mostly everyday activities, keeping them awake too late at night. Adults above 18 years sleep between 21:00 and 22:00, while the under-five sleep immediately after dinner, between 19:00 and 20:00. There is a slight difference in hours they woke-up between school-age children and adults, while the under-five wake up late. The two age groups wake up between 04.00 and 05.00 when the school-age children are getting ready for school while those above 18 are getting ready for prayers (Muslims) or going to the farm, but most of the under-five wake up at 07:00. With no variation, all participants from peri-urban and rural said, all people in the community tend to sleep earlier during rainy season compared to dry season because of rain and cold weather.

"Above 18 years are sleeping at 22:00 hours and the under-five normally sleep early at 20:00, but the school Aged 24:00. Watching television keeps them awake to late hours and if it is a match day, they can come home very early on the morning" (Parent, Rufiji)

“Adults above 18 are sleeping at 21:00 and the school age is sleeping around 24 hours because the school-age like to watch movies which normally ends at 23:30 while the under-five are sleeping at 20:00 hours.” (Parent, Kilwa)

Bednet use and sleeping behaviors among school-age children.

Bednet remains the primary malaria prevention measure used across the study area, while only a few people use other measures like repellants, coils and wearing long sleeves clothes. Most school-age children in peri-urban and rural areas reported using bednets distributed by school net programs in primary schools. Other sources of bednets mentioned were antenatal and postnatal clinics and local shops. Bednet use behaviors are likely to increase school-age children's vulnerability to mosquito bites if not properly used despite the reported high bednet use. Bednet use behaviors included (i) sleeping behaviors and Ulalavi (the tendency of sprawling legs and hands while sleeping), and (ii) laziness on tucking bed nets but hot weather and lack of money to buy bednets were reported as reasons not to use a bed net.

i. Sleeping behavior and ulalavi

Parents in this study area sleep with the under-five and reported giving them more attention than the school children. Both school-age children and parents said more than three children shared a bed because an extended family lifestyle is common across the study area. More importantly, Ulalavi was mentioned to be very common to younger school-age children than other age groups.

"….in our community, we call this behavior ulalavi, one sprawls legs and hands while sleeping, so if three children with this behavior sleep on one bed, they will touch the net. By doing so, mosquitoes will bite them and the bed net’s effectiveness will be low” (Parent, Rufiji)

"Children start sleeping alone when reaching five years and parents' care offered to the under-five is not the same as that given to school-age children. Very rarely, parents will check if the school-age children are using bed net or not because we believe they can take care of themselves” (Parents, Kibiti)

“Sleeping behaviors of children are different to adults. Ulalavi makes them touch the bednets frequently and be at more risk of being bitten by mosquitoes than others." (Parent, Kibiti)

ii. Laziness to tuck in bed net.

School-age children were reported not to tuck bed nets because they are tired after many hours of playing. However, only a few parent participants said other school-age children are not interested in using bednets despite their having and knowing the importance of using them. School-age children confirmed this and said the younger school children (5 to 10 years) are the ones who can fall asleep in any place, even outside the house, and if they don’t get immediate assistance, there is a high chance of sleeping without a bednet till morning.

"You can come back home late and at that time, children slept without bednet because of their laziness tucking the net" (Parent, Rufiji)

Risk perception on outdoor mosquito bites

Regardless of different levels of education, almost all participants across the study area believed mosquito bites in the evening hours before bed cannot transmit malaria because infectious mosquitoes bite only in the past midnight hours. Very few confirmed that being outdoors before bedtime is malaria risk behavior and that people should use repellants that are available in local shops, but money has been mentioned as the central obstacle because the majority cannot afford to buy them. All participants perceived ulalavi (the tendency of sprawling legs and hands while sleeping) as a risk behavior exposing school-age children to infectious mosquito bites despite using the bed net.

"We are not using protection when attending night studying sessions for a few hours from 20:00 to 22:00 because I know mosquitoes transmit malaria bites in the midnight hours and not before that time." (School-age child, Kilwa)

“Mosquitoes that transmit malaria bites in past midnight only and at that time we are in bednets” (School age child, Rufiji)

This study intended to explore activities and behaviors that increase the vulnerability of school-age children to malaria transmission risk. The finding shows that routine and seasonal outdoor activities and risky bed net use behavior are behind the persistently high prevalence of malaria parasites in the age group in the three districts of south-eastern Tanzania. The risk activities and drivers for high prevalence included: routine night studying sessions, late night sleeping behavior of school-age children compared to other age groups, migration of parents to farms, traditional initiation ceremonies, attending night social parties, and ulalavi (the tendency of sprawling legs and hands while sleeping).

Routine night studying sessions predispose school-age children to mosquito bites since they do not use protective measures. Unfortunately, entomological studies have reported a substantial proportion of biting mosquitoes before midnight (34–37). The under-five may be protected against such risk as they would be at home and under bednets early. This difference in exposure time between school-age children and children under five years may be one of the fundamental reasons for the difference in the burden of malaria between children under-five and school-age children similar in another context (38). In malaria-endemic areas, school-age children will remain vulnerable to malaria infections unless measures are taken to provide protective measures during night studying sessions (39).

Attending seasonal social parties may be one of the main risk behaviors that might increase the age group's vulnerability to malaria infection. In addition, the local music mostly liked by youth in the study and usually played from evening to past midnight hours attracts more school-age children than others. Currently, Vigodoro is common and famous in Tanzania's south and coastal zones while gaining popularity in other parts of the country. This practice, which has comprehensive geographical coverage and attracts a good number of school-age children, may continue to be a source of malaria infection in this age group if appropriate measures are not taken.

Traditional male initiation ceremonies are also essential risky activities contributing to the malaria prevalence in the school-age group in rural sites in the study area. During the initiation time, a group of boys stayed in the forest for 2 to 3 weeks without using malaria preventive measures, despite awareness of the risk of malaria transmission at night. In Tanzania, male initiation ceremonies are common practice in large parts of the country, especially the southern and coastal regions(40). These are also areas with high malaria transmission and burden. Thus, it is likely that the practice puts a substantial number of school-age male children at risk of infections compared to other age groups (40). Although girls do not stay in the forest like boys, their initiation ceremonies are held at home, attracting relatives and friends in overnight celebrations. As a cultural aspect, these practices may not be possible to abolish, and thus continue to sustain transmissions unless measures are taken to protect the respective group.

From December to June, parents migrate to farmlands to protect crops from animals and conduct other agricultural activities. As a result, the under-five continued to be safe from mosquito bites. At the same time, the school-age children remained behind unsupervised, affecting proper net use, which is essential for protecting against the disease. If the bednet is not used correctly, there is the possibility of being infected regardless of the daily net use (33). Unfortunately, the farm's seasonal migration pattern coincides with the high rainfall and increased breeding of mosquitoes in the study area (27). These findings coupled with similar results reported in other studies conducted in Tanzania (37, 41).

Other reported activities would also increase the vulnerability of contracting malaria among school-age children, but studies conducted in different contexts reported similar activities exposing all age groups and therefore there is a shared risk (36, 38, 40, 42–44).

Ulalavi is a most common behavior among school-age children of 5 to 10 years and could be one of the main possible reasons for higher malaria prevalence among school-age children. The age group is at more risk of mosquito biting when more than three children share a bed, then touching a bednet is inevitable. Ulalavi has been mentioned elsewhere as a reason for high malaria prevalence among bed-net users (33). Ulalavi can increase vulnerability to malaria infection among school-age children despite the coverage of bednet distribution programs and the supreme net use reported in the study.

Almost all participants across the study area were unaware of the risk of contracting malaria before bedtime, implying that they could not take any possible protective measures against mosquitoes. Most believe mosquitoes transmit malaria bites at midnight due to knowledge provided by the mass campaigns in Tanzania (45). Similar perception has been reported by other studies conducted elsewhere (36, 45, 46). This knowledge gap calls for community education to update and inform the community about the outdoor transmission risk before bedtime and its contribution to residual malaria transmission (36, 37, 40, 46).

Evidence presented in this study should be viewed in line with some limitations. This study focused mainly on activities and behavior that increased the vulnerability of the school-age children to malaria infection, not what the other groups were doing while the school-age group was engaged in the mentioned activities. However, this does not affect the findings presented. Therefore, there is a need to conduct a mixed-method study to link human and vector species behaviors to explore and quantify risk between age groups at the household level in the study area.

Results of this study indicate that school-age children are vulnerable to infectious mosquito biting before bedtime and bednet is the only malaria control intervention. The outdoor nighttime activities keep them in one place for a long period increasing exposure to mosquito bites. The findings of this study are useful to the National Malaria Control Program and collaborators in designing interventions that would appropriately target the group to control the parasite reservoir and transmission of the disease(47, 48) and more importantly, it encourages integrating outdoor malaria vector control measures to the existing ones to achieve malaria elimination (39). Moreover, these findings encourage the improvement of housing(49–53) and call for an urgent need for community education to inform people about outdoor exposure and its contribution to malaria infection, to seal the existing knowledge gap to improve individual malaria protection behaviors against infectious mosquitoes (36, 44, 46, 54, 55)

NMCP: National Malaria Control Programme; IHI: Ifakara Health Institution; MUHAS: Muhimbili University of Health and Allied Sciences; 1,7-mRCTR: 1,7-malaria Reactive Community-Based Testing and Response; ITNs: Insecticide Treated Nets; IRS: Indoor Residual Spray; ACOBISREM: Community-Based Integrated Strategies to Reduce Malaria; FGD: Focus Group Discussion.

Authors’ contributions.

F.K. wrote the study proposal, concept, methodology, and tools. B.S. and P.C. reviewed the work, B.S. supervised the study process, F.K. and T.G. data collection, F.K. data analysis, F.K. drafted the original manuscript, B.S., P.S., T.G., YM CM and H.M. provided further revisions of the manuscript, F.K., BS, P.C., N.G., T.G., and Y.M. reviewed the manuscript. All authors read and approved the final manuscript.

Authors detail.

¹Environmental Health and Ecological Sciences Department, Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, United Republic of Tanzania.

²Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, United Republic of Tanzania.

³Pan African Mosquito Control Association, Nairobi, Kenya.

Acknowledgments

The authors are indebted to acknowledge District Medical Officers in the three districts of south-eastern Tanzania: Kilwa, Rufiji and Kibiti for accepting to conduct this study in these areas. Also, the authors appreciate the cooperation offered by teachers and village leaders in selecting study participants and organizing focus group discussions in schools and at the village offices. Significantly authors would like to thank Professor Xiao-Nong Zhou and Dr. Prosper Chaki, Principal Investigators of the ACOBISREM project for leading the implementation of the project and offering endless support on the facilitation of research cost for this study. Last but not least, the authors would like to acknowledge the continuous and tireless support provided by Dr. Zawadi Mageni Mboma, Dr. Abela Mpobela, Dr. Kassim Mahende, Dr. George Longopa, Dr. Prosper Njau, Victor Mponzi, Michael Mihayo, Exavery Chaki, Protas Sayo, Godlove Chilla, Silas Temu, Felix Brown, Siglibert Mrema, Maneno Baravuga and FSAT team supervisors and our drivers Mr. Achilius Edward and Mr. Michael Mushi for their contribution on this study.

Competing interests

The authors declare that they have no conflict of interest.

Availability of data and materials.

Data can be made available upon receipt of official requests, and it must ensure participants' confidentiality and data privacy.

Ethical approval and consent to participate.

The Muhimbili Health of Allied Sciences Research and Ethics Committee approved the conduct of this study (IRB number 04-2021-560). The study was given permission by the district medical officers for Kilwa, Kibiti and Rufiji districts. All study participants had to consent to participate in the study through written informed consent after understanding the aim and procedures of the study. The participants who were under 18 years and interested in participating gave their assent and their parents gave consent for their participation. Participants were assured of the confidentiality and privacy of the information they shared.

Funding.

This work was supported by Ifakara Health Institute (IHI), where the Principal investigator was employed under the project called Application of Integrated Community-based Interventions to Reduce Malaria (ACOBISREM) funded by Bill and Melinda Gates Foundation (BMGF) through the National Institute of Parasitic Diseases (NIPD) of the Chinese Centre for Disease Control and Prevention (China CDC).

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Table 1 is available in the Supplementary Files section.

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Outdoor activities and behaviors increase the vulnerability of school-age children to malaria infections in south-eastern Tanzania

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